Gastric Varices: Causes, Risk Factors, Symptoms, Diagnosis, Treatment, and Prevention

Gastric varices are enlarged veins within the lining of the stomach that develop when blood flow through the liver is impaired, causing portal hypertension. These dilated vessels carry a high risk of rupture and bleeding, which can be life threatening. Early recognition of risk factors, prompt diagnosis, and effective management are key to preventing complications. This article explores the causes, risk factors, signs, diagnostic steps, treatment options, and prevention strategies for gastric varices.

What Are Gastric Varices?

Gastric varices are swollen, fragile veins in the stomach wall that arise due to increased pressure in the portal venous system. When blood cannot flow freely through a diseased liver, pressure builds up in the portal vein and is redirected through collateral vessels. In the stomach, this redirected flow causes veins to dilate and form varices that can bleed heavily if they rupture.

Causes and Risk Factors

Understanding the underlying causes and contributing risk factors helps identify at-risk patients and guide monitoring efforts.

Portal Hypertension

The most common cause of gastric varices is portal hypertension, which occurs when elevated pressure in the portal vein forces blood to find alternate pathways. Conditions such as cirrhosis, fibrosis, or thrombosis within the liver obstruct normal blood flow, leading to increased venous pressure and the formation of varices in the stomach and esophagus.

Splenic Vein Thrombosis

A clot in the splenic vein can increase backpressure on the portal system and force blood into gastric collaterals. Splenic vein thrombosis may result from pancreatitis, pancreatic tumors, or trauma. Patients with this condition often present with isolated gastric varices without esophageal involvement.

Liver Disease and Cirrhosis

Chronic liver conditions such as alcoholic liver disease, chronic hepatitis B or C, and nonalcoholic steatohepatitis (NASH) lead to scarring and fibrosis. As liver tissue becomes fibrotic, resistance to portal blood flow increases, promoting the development of varices. Patients with advanced cirrhosis require regular surveillance for varices.

Pancreatic and Other Malignancies

Tumors in the pancreas or surrounding areas can compress or invade the splenic vein, causing localized venous hypertension. This localized pressure increase predisposes to gastric varices. Additionally, tumors in the liver itself can contribute to overall portal pressure elevation.

Symptoms and Clinical Presentation

Gastric varices often remain silent until bleeding occurs. Identifying warning signs and associated symptoms is crucial for early intervention.

Bleeding and Hematemesis

The most alarming symptom is vomiting of blood, which may be bright red or resemble coffee grounds. This indicates active bleeding from a ruptured varix and requires emergency care.

Melena and Hematochezia

Black, tarry stools (melena) are evidence of upper gastrointestinal bleeding that has been partially digested. In massive bleeding, patients may pass fresh blood per rectum (hematochezia). Both findings warrant urgent evaluation.

Signs of Portal Hypertension

Many patients with gastric varices show signs of advanced liver disease and portal hypertension before bleeding occurs. These include:

• Jaundice (yellow discoloration of skin and eyes)
• Ascites (abdominal fluid accumulation)
• Splenomegaly (enlarged spleen)
• Caput medusae (dilated abdominal wall veins)

Anemia and Fatigue

Chronic, slow bleeding from varices may lead to iron deficiency anemia, resulting in fatigue, weakness, and pallor. Routine blood tests may reveal low hemoglobin levels before any overt bleeding event.

Diagnosis and Evaluation

Timely diagnosis of gastric varices involves endoscopic and imaging studies to assess variceal size, location, and bleeding risk.

Upper Endoscopy

Endoscopic evaluation is the gold standard for detecting and grading gastric varices. During an upper endoscopy, a flexible scope with a camera visualizes the stomach lining. Gastric varices are classified based on size and location:

• Gastroesophageal varices type 1 (GOV1): Extend from the esophagus into the lesser curvature of the stomach
• Gastroesophageal varices type 2 (GOV2): Extend from the esophagus into the fundus of the stomach
• Isolated gastric varices type 1 (IGV1): Located in the fundus without esophageal varices
• Isolated gastric varices type 2 (IGV2): Located in the stomach body, antrum, or pylorus

Endoscopic grading also assesses for red wale marks or spots that indicate a high risk of bleeding.

Imaging Studies

In addition to endoscopy, imaging helps evaluate portal pressure and identify underlying causes:

• Contrast-enhanced CT scan: Visualizes cirrhosis, collateral vessels, and splenic vein thrombosis
• Magnetic resonance imaging (MRI): Provides detailed liver architecture and portal venous flow assessment
• Ultrasound with Doppler: Assesses portal vein diameter, flow velocity, and splenic vein patency
• Transient elastography (FibroScan): Measures liver stiffness to estimate fibrosis severity

Laboratory Tests

Blood tests evaluate liver function and bleeding risk:

• Liver enzymes (AST, ALT, ALP)
• Platelet count and coagulation profile (INR, PT)
• Serum bilirubin and albumin levels
• Complete blood count to detect anemia

Treatment Options

Management of gastric varices aims to prevent first bleeding, control acute hemorrhage, and reduce portal hypertension. Treatment is often tailored to variceal type and patient condition.

Primary Prophylaxis

Preventing the first bleeding episode in high-risk patients involves:

• Nonselective beta blockers: Medications such as propranolol or nadolol reduce portal pressure by decreasing cardiac output and splanchnic blood flow. These are indicated for patients with medium to large varices and no contraindications.
• Endoscopic variceal ligation (EVL): Rubber bands are applied during endoscopy to ligate varices. EVL is recommended for GOV1 and medium to large GOV2 varices to prevent first bleeding.
• Endoscopic cyanoacrylate injection: For IGV1 and large fundal varices, injection of tissue adhesive into the variceal lumen achieves rapid hemostasis and obliteration.

Management of Acute Bleeding

When gastric varices rupture, urgent intervention is critical:

1. Resuscitation: Establish intravenous access, transfuse blood products, correct coagulopathy, and stabilize airway.
2. Intravenous vasoactive drugs: Octreotide or terlipressin reduces splanchnic blood flow and portal pressure.
3. Urgent endoscopy: Perform as soon as hemodynamically stable. Cyanoacrylate injection or EVL is used depending on variceal type.
4. Balloon tamponade: A temporary measure using a Sengstaken-Blakemore tube to compress fundal varices until definitive therapy.
5. Antibiotic prophylaxis: Administer broad-spectrum antibiotics (e.g., ceftriaxone) to reduce infection risk and improve survival.
6. Transjugular intrahepatic portosystemic shunt (TIPS): Reserved for refractory bleeding despite endoscopic and pharmacologic therapy. TIPS lowers portal pressure by creating a shunt between the portal and hepatic veins.

Secondary Prophylaxis

After controlling an acute bleed, preventing rebleeding involves:

• Repeat cyanoacrylate injection or band ligation: Scheduled sessions until variceal eradication.
• Nonselective beta blockers: Continue long-term therapy to maintain reduced portal pressure.
• TIPS: Consider early in patients with high risk of rebleeding or failure of endoscopic therapy.
• Balloon-occluded retrograde transvenous obliteration (BRTO): An alternative to TIPS for gastric varices in centers with expertise. BRTO obliterates varices by injecting sclerosant through a shunt.

Preventive Measures and Lifestyle Modifications

In addition to medical and endoscopic therapies, lifestyle changes can help reduce portal hypertension progression and lower bleeding risk.

Diet and Nutrition

A balanced diet supports liver health and reduces portal pressure:

• Consume fruits, vegetables, lean proteins, and whole grains.
• Limit sodium intake to control ascites and edema.
• Avoid raw or undercooked shellfish to prevent bacterial infections.

Weight Management

Maintaining a healthy weight can reduce liver fat and inflammation, decreasing disease progression in nonalcoholic fatty liver disease. Regular weight checks and guidance from a dietitian are recommended.

Exercise and Physical Activity

Moderate exercise improves circulation and overall fitness. Safe activities include walking, swimming, and yoga. Patients with advanced disease should consult their provider before starting any new routine.

Avoiding Alcohol and Toxins

Alcohol accelerates liver damage and worsens portal hypertension. Patients with any liver disease should abstain from alcohol. Avoid over-the-counter medications that can harm the liver, such as high doses of acetaminophen, without consulting a healthcare provider.

Long-Term Monitoring and Follow-Up

Regular follow-up is essential for patients with diagnosed gastric varices or underlying liver disease:

• Surveillance endoscopy: Repeat every 6 to 12 months for those with medium or large varices. Small varices are rechecked every 1 to 2 years.
• Liver function tests: Monitor transaminases, bilirubin, albumin, and coagulation profile every 3 to 6 months.
• Imaging studies: Abdominal ultrasound with Doppler annually to assess portal vein flow and screen for hepatocellular carcinoma.
• Clinical evaluation: Assess for new symptoms such as ascites, encephalopathy, or worsening jaundice at each visit.

Future Directions and Research

Advances in endoscopic techniques, pharmacotherapy, and interventional radiology continue to improve outcomes for gastric varices:

• Enhanced imaging modalities: High-resolution endoscopy and capsule endoscopy may detect smaller varices earlier.
• Novel endoscopic treatments: Biodegradable clips and newer sclerosants under investigation to reduce complications.
• Refined TIPS technology: Covered stents and hemodynamic monitoring to reduce post-TIPS encephalopathy.
• Genetic and biomarker studies: Identifying patients at highest risk for bleeding to tailor individualized therapy.

Conclusion: The Importance of Proactive Management

Gastric varices represent a serious complication of portal hypertension with high morbidity and mortality if bleeding occurs. Early recognition of risk factors such as cirrhosis, splenic vein thrombosis, and portal hypertension allows for timely intervention. Comprehensive care includes surveillance endoscopy, medical therapy with beta blockers, endoscopic variceal ligation or cyanoacrylate injection, and interventional procedures such as TIPS or BRTO when indicated. Patients benefit from lifestyle modifications that support liver health and reduce portal pressure. Regular monitoring and multidisciplinary collaboration between hepatologists, gastroenterologists, and interventional radiologists provide the best chance to prevent bleeding and improve long-term outcomes.

Disclaimer: This article is intended for informational purposes only and does not constitute medical advice, diagnosis, or treatment. The content provided should not be used as a substitute for professional medical advice, diagnosis, or treatment. Always consult with a qualified healthcare professional before making any decisions about your health or medical conditions. Never disregard or delay seeking professional medical advice due to the information provided in this article. The author and publisher of this article are not responsible or liable for any adverse outcomes resulting from the use or reliance on the information provided herein.